Quality Nurse/Medical Records Nurse

Freedom Magnolia•Magnolia, MS

14d•Onsite

About The Position

The Quality Nurse / Health Information Management (HIM) Director is responsible for the oversight, coordination, and continuous improvement of clinical quality, patient safety, and health information management functions within the facility. This role integrates Quality Assurance and Performance Improvement (QAPI) activities with medical record integrity and regulatory compliance, ensuring alignment with the Centers for Medicare & Medicaid Services Conditions of Participation, The Joint Commission standards, and all applicable state regulations. Reporting directly to the Hospital Administrator and working closely with the Corporate Compliance Nurse, this position leads facility-wide quality initiatives, conducts clinical audits, and ensures the accuracy, completeness, confidentiality, and accessibility of patient health information. The incumbent coordinates and manages the facility’s QAPI program by developing and tracking quality metrics, conducting clinical and documentation audits, identifying trends and performance gaps, and implementing corrective action plans to improve outcomes. The role facilitates QAPI and performance improvement committee activities, supports root cause analyses, ensures timely reporting of incidents and grievances, and promotes a culture of continuous improvement and survey readiness. In collaboration with nursing, medical staff, and department leaders, the Quality Nurse provides education, monitors compliance, and ensures adherence to established clinical and regulatory standards. In the Health Information Management capacity, the position is responsible for the operational oversight of the HIM department, ensuring all medical records are maintained in a complete, accurate, and timely manner in accordance with facility policy and regulatory requirements. This includes managing chart assembly and approved closed record order, monitoring physician documentation deficiencies, ensuring record completion within required timeframes, and maintaining the secure storage and accessibility of medical records at all times. The role oversees release of information processes, ensuring proper authorization and compliance with HIPAA privacy and security requirements, and coordinates documentation workflows with external coding and billing organizations. Additionally, the Quality Nurse / HIM Director serves as the facility’s subject matter expert on medical record content, documentation standards, and regulatory compliance, ensuring ongoing readiness for surveys and audits. The position supports the development and maintenance of policies and procedures, maintains required documentation and audit trails, and ensures that all activities are conducted in accordance with organizational policies, QAPI standards, and federal and state regulations. This role is critical to maintaining the integrity of patient care delivery and documentation, ensuring both high-quality clinical outcomes and full regulatory compliance across the organization.

Requirements

Graduate of an accredited School of Nursing
Current nursing license
Minimum 2 years clinical nursing experience
Proficient in EMR systems and data reporting tools
Ability to educate and mentor clinical staff on quality practices
Knowledge of CMS, Joint Commission, and state regulatory standards
Proficient in Microsoft Word, Excel, Outlook, and Adobe Acrobat

Nice To Haves

BSN preferred
Prior experience in Quality Improvement, Risk Management, or Infection Control preferred
CPHQ (Certified Professional in Healthcare Quality) preferred

Responsibilities

Oversight, coordination, and continuous improvement of clinical quality, patient safety, and health information management functions.
Integration of Quality Assurance and Performance Improvement (QAPI) activities with medical record integrity and regulatory compliance.
Ensuring alignment with CMS Conditions of Participation, The Joint Commission standards, and applicable state regulations.
Leading facility-wide quality initiatives.
Conducting clinical audits.
Ensuring accuracy, completeness, confidentiality, and accessibility of patient health information.
Coordinating and managing the facility’s QAPI program.
Developing and tracking quality metrics.
Conducting clinical and documentation audits.
Identifying trends and performance gaps.
Implementing corrective action plans to improve outcomes.
Facilitating QAPI and performance improvement committee activities.
Supporting root cause analyses.
Ensuring timely reporting of incidents and grievances.
Promoting a culture of continuous improvement and survey readiness.
Providing education, monitoring compliance, and ensuring adherence to established clinical and regulatory standards in collaboration with nursing, medical staff, and department leaders.
Operational oversight of the HIM department, ensuring medical records are complete, accurate, and timely.
Managing chart assembly and approved closed record order.
Monitoring physician documentation deficiencies.
Ensuring record completion within required timeframes.
Maintaining secure storage and accessibility of medical records.
Overseeing release of information processes, ensuring proper authorization and HIPAA compliance.
Coordinating documentation workflows with external coding and billing organizations.
Serving as the facility’s subject matter expert on medical record content, documentation standards, and regulatory compliance.
Ensuring ongoing readiness for surveys and audits.
Supporting the development and maintenance of policies and procedures.
Maintaining required documentation and audit trails.
Ensuring all activities are conducted in accordance with organizational policies, QAPI standards, and federal and state regulations.